Combination compositions for reducing intraocular pressure

Abstract

Provided herein is a pharmaceutical composition or a kit comprising a combination of a carbonic anhydrase inhibitor analog and an adenosine A 1 receptor agonist. Also provided herein is a method of reducing intraocular pressure (IOP) in a subject using such a combination or kit. In a particular embodiment, provided herein is a combination of dorzolamide marketed under the brand Trusopt™ and Compound A.

The invention claimed is: 
     
       1. An ophthalmic composition comprising
 i) an adenosine A 1  receptor agonist compound of formula (I), 
 
       
         
           
           
               
               
           
         
         or pharmaceutically acceptable salts thereof; 
         wherein
 A is —CH 2 OH, —(CH 2 ) n ONO 2 , —CH 2 OSO 3 Na or —CH 2 OSO 3 H; wherein n=1-6; 
 B and C are —OH; 
 D is 
 
       
       
         
           
           
               
               
           
         
         
           A and B are trans with respect to each other; 
           B and C are cis with respect to each other; 
           C and D are cis or trans with respect to each other; 
           R 1  is —H, —C 1 -C 10  alkyl, -aryl, -3- to 7-membered monocyclic heterocyclyl, -8- to 12-membered bicyclic heterocyclyl, —C 3 -C 8  monocyclic cycloalkyl, —C 3 -C 8  monocyclic cycloalkenyl, —C 8 -C 12  bicyclic cycloalkyl, —C 8 -C 12  bicyclic cycloalkenyl —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), or —(CH 2 ) n -aryl; 
           R 2  is —H, halo, —CN, —NHR 4 , —NHC(O)R 4 , —NHC(O)OR 4 , —NHC(O)NHR 4 , —NHNHC(O)R 4 , —NHNHC(O)OR 4 , —NHNHC(O)NHR 4 , or —NH—N═C(R 6 )R 7 ; 
           R 4  is —C 1 -C 15  alkyl, -aryl, —(CH 2 ) n -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), —C≡C—(C 1 -C 10  alkyl) or —C≡C-aryl; 
           R 6  is —C 1 -C 10  alkyl, -aryl, —(CH 2 ) n -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), -phenylene-(CH 2 ) n COOH, or -phenylene-(CH 2 ) n COO—(C 1 -C 10  alkyl); 
           R 7  is —H, —C 1 -C 10  alkyl, -aryl, —(CH 2 ) n -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl) or —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl) and each n is independently an integer ranging from 1 to 5, 
           wherein -3- to 7-membered monocyclic heterocyclyl is a 3- or 4-membered non-aromatic monocyclic cycloalkyl in which 1 of the ring carbon atoms has been replaced with an N, O or S atom; or a 5-, 6-, or 7-membered aromatic or non-aromatic monocyclic cycloalkyl in which 1-4 of the ring carbon atoms have been independently replaced with a N, O or S atom, 
           wherein -8- to 12-membered bicyclic heterocyclyl is a bicyclic 8- to 12-membered aromatic or non-aromatic bicyclic cycloalkyl in which one or both of the rings of the bicyclic ring system have 1-4 of its ring carbon atoms independently replaced with a N, O or S atom, and 
         
         ii) a carbonic anhydrase inhibitor. 
       
     
     
       2. The composition according to  claim 1  wherein the carbonic anhydrase inhibitor is selected from the group consisting of dorzolamide, brinzolamide and acetazolamide. 
     
     
       3. The composition according to  claim 1  wherein the carbonic anhydrase inhibitor is dorzolamide. 
     
     
       4. The composition according to  claim 1 ,
 wherein 
 A is —(CH 2 ) n ONO 2 ; 
 R 1  is −3- to 7-membered monocyclic heterocyclyl, —C 3 -C 8  monocyclic cycloalkyl, or —C 8 -C 12  bicyclic cycloalkyl; 
 R 2  is —H or halo; and 
 C and D are trans with respect to each other. 
 
     
     
       5. The composition according to  claim 4 ,
 wherein 
 R 1  is —C 3 -C 8  monocyclic cycloalkyl; and 
 R 2  is —H. 
 
     
     
       6. The composition according to  claim 4 ,
 wherein 
 n is 1. 
 
     
     
       7. The composition according to  claim 1  wherein the compound of Formula I is selected from the group consisting of: 
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(2-chloro-6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         sodium((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl sulfate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-3,4-dihydroxy-5-(6-(tetrahydrofuran-3-ylamino)-9H-purin-9-yl)tetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(6-(cyclohexylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(6-(bicycle-[2.2.1]-heptan-2-ylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         sodium((2R,3S,4R,5R)-5-(2-chloro-6-(cyclohexylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl sulfate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(2-chloro-6-(cyclohexylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate 
       
       
         
           
           
               
               
           
         
         (2R,3R,4S,5R)-2-(6-(cyclopentylamino)-9H-purin-9-yl)-5-(hydroxymethyl)tetrahydrofuran-3,4-diol (N 6 -cyclopentyl adenosine (CPA)), and 
       
       
         
           
           
               
               
           
         
         (2R,3R,4S,5R)-2-(2-chloro-6-(cyclopentylamino)-9H-purin-9-yl)-5-(hydroxymethyl)tetrahydrofuran-3,4-diol (2-chloro-N 6 -cyclopentyl adenosine (CCPA)); 
       
       or pharmaceutically acceptable salts thereof. 
     
     
       8. The composition according to  claim 1  wherein the adenosine A 1  agonist is Compound A, ((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate or a pharmaceutically acceptable salt thereof. 
     
     
       9. An ophthalmic pharmaceutical composition comprising dorzolamide, an adenosine A 1  receptor agonist according to  claim 1 , and a pharmaceutically acceptable vehicle or excipient. 
     
     
       10. The pharmaceutical composition of  claim 9 , wherein the pharmaceutically acceptable vehicle or excipient is selected from the group consisting of: ophthalmologically acceptable preservatives, surfactants, viscosity enhancers, penetration enhancers, gelling agents, hydrophobic bases, vehicles, buffers, sodium chloride, and water, or any combination thereof. 
     
     
       11. A kit comprising
 i) an adenosine A 1  receptor agonist compound of formula (I), 
 
       
         
           
           
               
               
           
         
         or pharmaceutically acceptable salts thereof; 
         wherein
 A is —CH 2 OH, —(CH 2 ) n ONO 2 , —CH 2 OSO 3 Na or —CH 2 OSO 3 H; wherein n=1-6; 
 B and C are —OH; 
 D is 
 
       
       
         
           
           
               
               
           
         
         
           A and B are trans with respect to each other; 
           B and C are cis with respect to each other; 
           C and D are cis or trans with respect to each other; 
           R 1  is —H, —C 1 -C 10  alkyl, -aryl, -3- to 7-membered monocyclic heterocyclyl, -8- to 12-membered bicyclic heterocyclyl, —C 3 -C 8  monocyclic cycloalkyl, —C 3 -C 8  monocyclic cycloalkenyl, —C 8 -C 12  bicyclic cycloalkyl, —C 8 -C 12  bicyclic cycloalkenyl —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), or —(CH 2 ) n -aryl; 
           R 2  is —H, halo, —CN, —NHR 4 , —NHC(O)R 4 , —NHC(O)OR 4 , —NHC(O)NHR 4 , —NHNHC(O)R 4 , —NHNHC(O)OR 4 , —NHNHC(O)NHR 4 , or —NH—N═C(R 6 )R 7 ; 
           R 4  is —C 1 -C 15  alkyl, -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), —C≡C—(C 1 -C 10  alkyl) or —C≡C-aryl; 
           R 6  is —C 1 -C 10  alkyl, -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), -phenylene-(CH 2 ) n COOH, or -phenylene-(CH 2 ) n COO—(C 1 -C 10  alkyl); 
           R 7  is —H, —C 1 -C 10  alkyl, -aryl, —(CH 2 ) n -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl) or —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl) and each n is independently an integer ranging from 1 to 5, 
           wherein -3- to 7-membered monocyclic heterocyclyl is a 3- or 4-membered non-aromatic monocyclic cycloalkyl in which 1 of the ring carbon atoms has been replaced with an N, O or S atom; or a 5-, 6-, or 7-membered aromatic or non-aromatic monocyclic cycloalkyl in which 1-4 of the ring carbon atoms have been independently replaced with a N, O or S atom, 
           wherein -8- to 12-membered bicyclic heterocyclyl is a bicyclic 8- to 12-membered aromatic or non-aromatic bicyclic cycloalkyl in which one or both of the rings of the bicyclic ring system have 1-4 of its ring carbon atoms independently replaced with a N, O or S atom, and 
         
         ii) a carbonic anhydrase inhibitor. 
       
     
     
       12. The kit according to  claim 11 , wherein the carbonic anhydrase inhibitor is selected from the group consisting of dorzolamide, brinzolamide and acetazolamide. 
     
     
       13. The kit according to  claim 11 , wherein the carbonic anhydrase inhibitor is dorzolamide. 
     
     
       14. The kit according to  claim 11 , wherein the compound of Formula I is selected from the group consisting of: 
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(2-chloro-6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         sodium((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl sulfate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-3,4-dihydroxy-5-(6-(tetrahydrofuran-3-ylamino)-9H-purin-9-yl)tetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(6-(cyclohexylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(6-(bicycle-[2.2.1]-heptan-2-ylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate, 
       
       
         
           
           
               
               
           
         
         sodium((2R,3S,4R,5R)-5-(2-chloro-6-(cyclohexylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl sulfate, 
       
       
         
           
           
               
               
           
         
         ((2R,3S,4R,5R)-5-(2-chloro-6-(cyclohexylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate 
       
       
         
           
           
               
               
           
         
         (2R,3R,4S,5R)-2-(6-(cyclopentylamino)-9H-purin-9-yl)-5-(hydroxymethyl)tetrahydrofuran-3,4-diol (N 6 -cyclopentyl adenosine (CPA)), and 
       
       
         
           
           
               
               
           
         
         (2R,3R,4S,5R)-2-(2-chloro-6-(cyclopentylamino)-9H-purin-9-yl)-5-(hydroxymethyl)tetrahydrofuran-3,4-diol (2-chloro-N 6 -cyclopentyl adenosine (CCPA)); 
       
       or pharmaceutically acceptable salts thereof. 
     
     
       15. The kit according to  claim 11 , wherein the adenosine A 1  agonist is Compound A, ((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate or a pharmaceutically acceptable salt thereof. 
     
     
       16. An ophthalmic composition comprising ((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate and dorzolamide or pharmaceutically acceptable salts thereof. 
     
     
       17. A method of treating an eye disorder in a subject, comprising administering to an eye of the subject in need thereof, an effective amount of i) an adenosine A 1  receptor agonist compound of formula (I), 
       
         
           
           
               
               
           
         
         or pharmaceutically acceptable salts thereof; 
         wherein
 A is —CH 2 OH, —(CH 2 ) n ONO 2 , or —CH 2 OSO 3 H; wherein n=1-6; 
 B and C are —OH; 
 D is 
 
       
       
         
           
           
               
               
           
         
         
           A and B are trans with respect to each other; 
           B and C are cis with respect to each other; 
           C and D are cis or trans with respect to each other; 
           R 1  is —H, —C 1 -C 10  alkyl, -aryl, -3- to 7-membered monocyclic heterocyclyl, -8- to 12-membered bicyclic heterocyclyl, —C 3 -C 8  monocyclic cycloalkyl, —C 3 -C 8  monocyclic cycloalkenyl, —C 8 -C 12  bicyclic cycloalkyl, —C 8 -C 12  bicyclic cycloalkenyl —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), or —(CH 2 ) n -aryl; 
           R 2  is —H, halo, —CN, —NHR 4 , —NHC(O)R 4 , —NHC(O)OR 4 , —NHC(O)NHR 4 , —NHNHC(O)R 4 , —NHNHC(O)OR 4 , —NHNHC(O)NHR 4 , or —NH—N═C(R 6 )R 7 ; 
           R 4  is —C 1 -C 15  alkyl, -aryl, —(CH 2 ) n -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), —C≡C—(C 1 -C 10  alkyl) or —C≡C-aryl; 
           R 6  is —C 1 -C 10  alkyl, -aryl, —(CH 2 ) n -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), -phenylene-(CH 2 ) n COOH, or -phenylene-(CH 2 ) n COO—(C 1 -C 10  alkyl); 
           R 7  is —H, —C 1 -C 10  alkyl, -aryl, —(CH 2 ) n -aryl, —(CH 2 ) n -(3- to 7-membered monocyclic heterocyclyl), —(CH 2 ) n -(8- to 12-membered bicyclic heterocyclyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkyl), —(CH 2 ) n —(C 3 -C 8  monocyclic cycloalkenyl), —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkenyl) or —(CH 2 ) n —(C 8 -C 12  bicyclic cycloalkyl) and each n is independently an integer ranging from 1 to 5, 
           wherein -3- to 7-membered monocyclic heterocyclyl is a 3- or 4-membered non-aromatic monocyclic cycloalkyl in which 1 of the ring carbon atoms has been replaced with an N, O or S atom; or a 5-, 6-, or 7-membered aromatic or non-aromatic monocyclic cycloalkyl in which 1-4 of the ring carbon atoms have been independently replaced with a N, O or S atom, 
           wherein -8- to 12-membered bicyclic heterocyclyl is a bicyclic 8- to 12-membered aromatic or non-aromatic bicyclic cycloalkyl in which one or both of the rings of the bicyclic ring system have 1-4 of its ring carbon atoms independently replaced with a N, O or S atom, and 
         
         ii) a carbonic anhydrase inhibitor or pharmaceutically acceptable salts thereof. 
       
     
     
       18. The method according to  claim 17 , wherein the eye disorder is elevated intraocular pressure. 
     
     
       19. The method according to  claim 17  wherein the A 1  receptor agonist compound is applied to an eye of the subject in need thereof, simultaneously, separately or sequentially to the application of the carbonic anhydrase inhibitor to the eye of the subject. 
     
     
       20. The method according to  claim 17  wherein the A 1  receptor agonist compound is applied to an eye of the subject in need thereof, simultaneously to the application of the carbonic anhydrase inhibitor to the eye of the subject. 
     
     
       21. The method according to  claim 17  wherein the A 1  receptor agonist compound is applied to an eye of the subject in need thereof, sequentially to the application of the carbonic anhydrase inhibitor to the eye of the subject. 
     
     
       22. The method according to  claim 17 , further comprising applying about 0.05 mg/ml to about 7.0 mg/ml of the A 1  receptor agonist compound with about 2% of a carbonic anhydrase inhibitor to an eye of the subject in need thereof, from 1 to 4 times daily. 
     
     
       23. The method according to  claim 17 , further comprising applying about 20-700 μg of the A 1  receptor agonist compound to an eye of the subject in need thereof, from 1 to 2 times daily. 
     
     
       24. The method according to  claim 17 , further comprising applying about 20-350 μg of the A 1  receptor agonist compound to an eye of the subject in need thereof, from 1 to 2 times daily. 
     
     
       25. The method according to  claim 17 , wherein the A 1  receptor agonist compound and the carbonic anhydrase inhibitor are administered topically as one or more eye drops to the eye of the subject in need thereof. 
     
     
       26. A method of reducing intraocular pressure (IOP) and associated diseases and conditions caused by elevated IOP in a subject comprising administering an effective amount of a composition according to  claim 1  to an affected eye of the subject in need thereof. 
     
     
       27. The method according to  claim 26 , wherein the diseases and conditions caused by elevated IOP in the subject are selected from the group consisting of normal-tension glaucoma, ocular hypertension (OHT), and primary open-angle glaucoma (POAG). 
     
     
       28. A method of treating an eye disorder in a subject, comprising administering to an eye of the subject in need thereof, an effective amount of ((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate and dorzolamide or pharmaceutically acceptable salts thereof. 
     
     
       29. The method of  claim 28 , wherein the eye disorder is elevated intraocular pressure. 
     
     
       30. The method according to  claim 28  wherein ((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate is applied to an eye of the subject in need thereof, simultaneously to the application of dorzolamide to the eye of the subject. 
     
     
       31. The method according to  claim 28  wherein ((2R,3S,4R,5R)-5-(6-(cyclopentylamino)-9H-purin-9-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methyl nitrate is applied to an eye of the subject in need thereof, sequentially to the application of dorzolamide to the eye of the subject.